^ 


t> 


% 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


.<i^l% 


^^ 


1.0 


111^^ 


I, 


m 


12.5 
2.2 


™    |j4     iin.^ 


I 


4.0 


2.0 


1.8 


1.25      1.4 

m 

M 

a"    — 

► 

V 


e 


/a 


°^i    ^ 


Photographic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


d 


\ 


;V 


^9) 


V 


<F 


:\ 


\ 


4^ 


o^ 


% 


^ 


..<S', 


e 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  fnstitute  for  Historical  IVIicroreproductions  /  Institut  Canadian  de  microreproductions  historlques 


C 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


0 

□ 
D 
D 
D 
D 
D 

D 
D 


D 


Coloured  covers/ 
Couverture  de  couieur 

Covers  damaged/ 
Couverture  endommag6e 

Covers  restored  and/or  laminated/ 
Couverture  restaur6e  et/ou  peliiculde 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  g^ographiques  en  couieur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couieur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couieur 

Bound  with  other  material/' 
Relid  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  re  liure  serr6e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  int6rieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanrhes  ajouties 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  6tait  possible,  ces  pages  n'ont 
pas  6t6  fiimdes. 

Additional  comments:/ 
Commentaires  suppldmentaires; 


L'Institut  a  microfilm^  le  meilleur  oxemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exempiaire  qui  sont  peut-Atre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  methods  normale  de  filmage 
sont  indiquis  ci-dessous. 


□   Coloured  pages/ 
Pages  de  couieur 

□    Pages  damaged/ 
Pages  endommagdes 

□    Pages  restored  and/or  laminated/ 
Pages  restaur^es  et/ou  pelliculdes 

E    Pages  discoloured,  stained  or  foxed/ 
Pages  d6color6es,  tachetdes  ou  piqudes 


□Pages  detached/ 
Pages  d^tachdes 


>/ 


D 
D 


Showthrough/ 
Transparence 


I      I    Quality  of  print  varies/ 


Quality  indgale  de  I'im^iMssion 

Includes  supplementary  material/ 
Comprend  du  matdriel  suppldmentaire 


Only  edition  available/ 
SeuSe  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  film6es  d  nouveau  de  fapon  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  filmd  au  taux  de  reduction  indiqui  ci-dessous. 

10X  14X  18X  22X 


26X 


30X 


y 

12X 


16X 


20X 


24X 


28X 


32X 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

IVIei'ical  Library 
IMcGill  University 
IMontreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  Iceeping  with  the 
filming  contract  specifications. 


L'exemplaire  filmi  fut  reproduit  grAco  i  la 
gAnArositA  de: 

IMedical  Library 
IMcGill  University 
IMontreal 

Les  images  suivantas  ont  4tA  reproduites  avec  le 
plus  grand  soin,  compta  tenu  de  la  condition  at 
de  la  nettet*  de  l'exemplaire  filmA,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  bacic  cover  when  appropriate.  All 
other  original  copies  are  filmed  b^ginrring  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


Lee  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimte  sont  filmte  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniire  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration.  soit  par  le  second 
plat,  salon  le  ess.  Tous  les  autres  exemplaires 
originaux  sont  filmis  en  commen9ant  par  la 
premiAre  page  qui  comporte  une  empreinte 
d'imprmsion  ou  d'illustration  et  en  terminant  par 
la  dernlAre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  •-^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Un  dee  symboles  sulvants  apparattra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbols  — *>  signifie  "A  SUIVRE",  le 
symbols  V  signifie  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratioa.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corr;er,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
filmis  A  des  taux  de  reduction  diff Arents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA,  il  est  filmA  A  partir 
de  I'angle  supArieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'imageo  nAcessaire.  Les  diagrammes  suivants 
illuatrent  la  mithode. 


r  t 

2 

3 

*» 

2 

3 

4 

5 

6 

ON  THE  APPLICATION  OF  THE  SERUM  DIAG- 
NOSIS OF  TYPHOID  FEVER  TO  THE  RE- 
QUIREMENTS OF  PUBLIC  HEALTH 
LABORATORIES. 


By  WYATT  JOHNSTON,  M.  D.,  Montreal, 

Bacteriologist  to  the  Board  of  Health  for  the  Province  of  Quebec;   As- 
sistant Professor  of  Hygiene,  McGill  University;  Pathologist  to 
THE  Montreal  GenjJRAl  Hospital. 


Reprinted  from  Transactions  of  the  American  Public  Health  Association. 


CONCORD,  N.H.: 
printed  by  the  republican  press  association. 

1897. 


a 


ON    THE    APPLICATION    OF    THE    SERUM    DIAGNOSIS    OF 

TYPHOID    FEVER    TO    THE    REQUIREMENTS    OF 

PUBLIC    HEALTH    LABORATORIES.' 


Great  interest  attaches  to  Widal's  important  communication  to  the 
effect  that  the  serum  of  persons  suffering  from  typhoid  fever,  even  in  the 
early  stages,  is  capable,  when  mixed  with  a  pure  culture  of  the  typhoid 
bacillus  in  bouillon,  of  arresting  the  active  movement  so  characteristic  of 
this  organism  and  causing  the  bacilli  to  agglutinate  into  clumps  resem- 
bling zoogloea.  The  serum  of  typhoid  convalescents  and  immunized  ani- 
mals had  been  shown  by  Pfeiffer,  Durham,  and  Gruber  to  possess  this 
property.  But  Widal  has  certainly  been  the  one  to  demonstrate  its  great 
clinical  value.  With  the  serum  of  an  undoubted  case  of  typhoid  fever 
we  are  able  to  apply  what  appears  to  be  the  most  conclusive  of  the  tests 
at  our  disposal  in  deciding  whether  a  given  organism  is  really  the  typhoid 
bacillus  or  not.  On  the  other  hand,  with  a  culture  of  the  genuine  typhoid 
bacillus,  we  are  able  to  decide  whether  a  doubtful  case  is  or  is  not 
typhoid  fever. 

Although  the  test  is  so  recent  in  origin,  those  who  have  tried  it  appear 
practically  unanimous  as  to  its  being  of  great  delicacy,  and,  in  particular, 
the  negative  results  which  it  furnishes  are  of  nearly  as  much  practical 
value,  something  which  can  scarcely  be  said  of  the  routine  bacterial  tests 
for  tuberculosis. 

Widal's  original  method  was  to  obtain  the  serum  from  the  vein  of  a 
patient's  arm  by  means  of  a  sterilized  syringe,  descanting  the  serum  after 
it  had  separated  and  adding  it  to  bouillon  culture  of  typhoid  bacilli.  This 
was  then  placed  in  the  incubator,  and  showed,  after  several  hoars,  a  floc- 
culent  precipitate  composed  of  the  immobilized  and  agglutinated  bacilli 
and  a  clearing  of  the  upper  part  of  the  fluid.  This  was  found  by  Widal 
to  be  characteristic  of  typhoid  blood.  The  blood  in  other  febrile  dis- 
orders, such  as  malaria,  typhus,  tuberculosis,  pyaemia,  etc.,  as  well  as  the 
serum  of  healthy  persons,  was  found  to  have  no  power  of  producing  this 
phenomena  when  mixed  with  typhoid  cultures.  Those  who  have  re- 
peated Widal's  experiments  have  also  been  able  to  confirm  his  statements 
that  the  colon  bacillus  does  not  give  this  reaction  with  typhoid  blood. 

Widal  was  fortunately  led  to  simplify  the  method  materially  by  taking 

'  Read  before  the  American  Public  Health  Association,  at  Buffalo,  N.  Y.,  September  17,  1896. 


SERUM  DIAGNOSIS  OF  TYPHOID  FEVER. 


a  few  drops  of  blood  from  the  finger  tip,  and  as  soon  as  the  serum  was 
separated  from  the  edge  of  this,  mixing  it  with  a  drop  of  actively  mobile 
typhoid  culture,  whereupon  the  reaction  could  be  satisfactorily  observed 
under  the  microscope  and  was  usually  complete  in  a  few  minutes.*  Dieu- 
lafoy  testifies  to  the  remarkable  accuracy  of  the  test  and  its  value  in  diag- 
nosticating obscure  cases. 

My  attention  was  first  directed  to  the  test  through  having  been  con- 
sulted by  physicians  as  to  the  nature  of  suspected  cases  of  typhoid,  and 
my  experience  has  been  thoroughly  in  accord  with  that  of  Widal  and 
others  as  to  its  great  value  as  an  aid  to  clinical  diagnosis. 

As  the  reaction  appeared  to  depend  probably  upon  the  presence  of 
some  substance  analogous  to  the  ordinary  toxines,  and  as  many  of  these 
preserve  their  characteristics  in  a  dry  state,  it  naturally  occurred  to  me 
that  this  might  be  true  of  the  substance  producing  thv.  serum  reaction. 
The  advantage  of  being  able  to  operate  with  a  dried  substance  was  obvi- 
ous, especially  with  reference  to  the  possible  application  of  the  method  to 
the  rapid  bacteriological  diagnosis  of  typhoid  fever  in  municipal  labora- 
tories, just  as  is  now  done  in  the  case  of  diphtheria,  and  my  observations 
have  been  made  with  this  end  in  view. 

Instead  of  taking  the  serum  as  soon  as  it  exuded,  I  allowed  the  drop 
to  dry,  and  found  that  upon  moistening  it  subsequently  the  solution  ob- 
tained was  just  as  efficacious  as  the  pure  serum  for  the  diagnostic  pur- 
poses of  the  test.'^ 

This  power  appears  to  remain  practically  unimpaired  even  after  the 
blood  has  been  allowed  to  dry  for  many  days.  My  experiments  upon 
how  long  the  blood  will  continue  to  react  when  in  this  dry  state  are  not 
yet  finished,  but  blood  drops  dried  for  from  two  to  four  weeks  still  give 
the  reaction. 

In  this  manner  I  have  tested  the  blood  of  ten  patients  suffering  from 
undoubted  and  typical  attacks  of  typhoid.  The  reaction  was  obtained 
conclusively  in  every  instance.  In  eight  cases  the  loss  of  mobility  and 
the  agglutination  was  complete  in  from  two  to  fifteen  minutes.  Of  the 
two  others,  one,  in  a  very  early  stage  of  the  disease,  required  thirty  min- 
utes for  the  completion  of  the  reaction,  while  the  other  in  a  very  late 
stage,  following  a  relapse,  required  one  hour. 

The  blood  of  ten  other  hospital  patients,  as  well  as  a  number  of  healthy 
individuals,  was  next  tested,  and  in  no  single  instance  was  the  reaction 
obtained.  Occasionally  a  pseudo-reaction  with  some  agglutination  was 
observed  within  a  few  minutes  of  the  mixture  of  blood  solution  and  cul- 
ture, but  some  movements  of  translation  (wandering  through  the  field) 


4 


5^1 


1  This  plan  of  observing  the  reaction  directly  under  the  microscope  had  been  published  by  Gru- 
ber  and  Durham  some  months  previously. 

» Since  writing  the  foregoing,  I  have  been  able  to  obtain  fuller  accounts  of  Widal's  work  than 
were  at  first  available,  and  find  it  stated  by  him  that  dried  serum,  and  to  a  lesser  extent  dried  blood, 
are  capable  of  furnishing  the  reaction.  This  circumstance  does  not  appear  to  have  been  hitherto 
utilized  practically. 


^tn 


f 


SERUM  DIAGNOSIS  OF  TYPHOID  FEVER.  % 

always  persisted  on  the  part  of  isolated  bacilli,  and  these  gradually  in- 
creased in  number  and  activity  till,  in  an  hour  or  two,  lively  motion  was 
resumed,  and  was  found  to  be  still  present  on  the  following  day  and,  in 
some  instances,  where  it  was  followed  up,  at  the  end  of  a  week.  With 
the  typhoid  bloods  nothing  but  the  oscillating  or  "  Brownian  "  move- 
ments were  seen,  as  a  rule,  though  where  the  proportion  of  serum  added 
was  very  small  peculiar  revolving  and  tugging  movements,  apparently 
due  to  the  action  of  the  flagella,  could  be  made  out,  movements  from  one 
part  to  another  of  the  microscopic  field  being,  however,  completely  abol- 
ished. 

In  two  doubtful  cases  examined  for  diagnosis  the  results  were  negative. 
In  one  of  these  the  malaria  Plasmodium  was  subsequently  detected.  The 
other  left  the  hospital  before  the  diagnosis  was  cleared  up,  but  her  tem- 
perature had  remained  normal  for  two  weeks,  and  her  only  symptoms 
were  persistent  headache  and  giddiness.  One  of  the  control  cases,  exam- 
ined with  negative  results,  had  a  history  of  typhoid  two  years  previ- 
ously. 

In  making  a  communication  upon  this  subject  before  tlie  American  Public  Health 
Association,  at  Buffalo,  N.  Y.,  on  September  17,  1896,  I  subjected  the  method  to  what  I 
considered  to  be  a  fair  practical  test  as  to  its  applicability  to  public  health  purposes. 
I  left  instructions  for  Dr.  D.  D.  McTaggart,  resident  pathologist,  to  forward  by  post  to 
my  destination,  after  I  had  left  Montreal,  a  letter  containing  dried  blood  drops  from  sev- 
eral cases  of  undoubted  typhoid  fever  and  also  dried  blood  drops  for  control  from  other 
hospital  cases,  preferably  patients  suffering  from  febrile  conditions,  but  making  sure 
that  they  had  not  had  typhoid  recently.  All  these  blood  drops  were  to  be  numbered 
and  a  key  giving  the  clinical  diagnosis  in  each  case  placed  within  a  separate  sealed 
envelope. 

I  left  Montreal  .September  13th.  Samples  of  blood  from  six  patients  were  collected) 
and  forwarded  as  directed,  on  September  I4ih.  On  September  i6th,  the  letter  was  deliv- 
ered unopened  at  Huffalo,  N.  Y.,  to  Dr.  IJissell,  the  city  bacteriologist  for  Buffalo,  who 
kindly  took  charge  of  the  key.  At  the  end  of  an  hour  spent  in  examining  the  specimens, 
I  wrote  my  diagnosis  upon  the  outside  of  the  sealed  envelope.  It  will  be  seen  from  the 
subjoined  signed  statement,  which  Dr.  Bissell  kindly  made  at  my  request,  that  the  results 
were  perfectly  in  accord  with  the  clinical  diagnosis  in  each  case,  while  the  specimens, 
which  were  then  examined  by  a  number  of  competent  bacteriologists,  showed  that  good 
objective  grounds  existed  for  arriving  at  the  conclusions  given. 

STATEMENT  I!Y  DR.  MCTAGGART,  RESIDENT  PATHOLOGIST,  MONTREAL  GENERAL  HOSPITAL. 

The  samples  of  blood  were  mailed  to  Dr.  Johnston  one  day  after  he  had  left  Montreal. 
Dr.  Johnston  had  no  knowledge  of  the  contents  of  the  "  key,"  and  no  private  means  of 
knowing  which  of  the  numbeis  referred  to  typhoid  and  which  to  non-typhoid  blood. 

(Signed)  D.  D.  McTaggart. 

STATE.MENT    iiY   DR.    BISSELL,   CITY   BACTERIOLOGIST,    BUFFALO,   N.   Y. 

Buffalo,  September  i6,  1896. 
Received  to-day  from  Dr.  Wyatt  Johnston  a  sealed  letter,  mailed  in  Canada,  with  post- 
mark, "  Montreal,  September  14,  1896."    This  was  opened  by  me  and  found  to  contain 

(a)  six  glass  cover  slips,  numbered  from  i  to  6,  with  a  drop  of  dried  blood  on  each,  and 

(b)  also  a  sealed  envelope  marked  "  key."  Received  from  Dr.  Johnston,  after  examining 
the  blood  by  the  (Widal)  serum  diagnostic  test,  the  following  report:  No.  i,  typhoid; 
No.  2,  typhoid ;  No.  3,  typhoid ;  No.  4,  not  typhoid ;  No.  5,  not  typhoid  ;  No.  6,  doubtful. 


6  SF.KUM  DIAGNOSIS  OF  TYPIfOID  FF.VER. 

probably  not  typhoid.  Tlie  key  was  then  opened  by  me,  and  the  clinical  diagnosis  from 
all  cases  found  as  follows:  No.  i,  typhoid;  No.  2,  typhoid;  No.  3,  typhoid;  No,  4, 
malaria;  No.  5,  enlarged  glands  of  neck;  No.  6,  h  art  disease. 

(Signed)  William  E.  Bissell. 

It  will  be  noticed  that  a  (pialified  though  correct  opinion  was  given  at  the  time  of  my 
making  the  report  in  one  of  the  negative  cases  (No.  6).  This  doubt  was  owing  to  the 
fact  that  it  was  the  last  specimen  examined,  and  that  a  partial  agglutination  appeared  to 
take  place  at  first,  though  motion  was  not  abolished.  Subseipient  examination  some 
hours  later  showed  sul!  lively  motion  that  I  should  have  had  no  hesitation  in  declaring 
it  not  to  be  typhoid,  had  the  circimistances  permitted  that  much  delay  before  an  opinion 
was  given. 

A  ready  means  of  diagnosis  in  typhoid  fever  is  something  which  has 
long  been  desired  by  sanitar  officials.  The  medical  profession  is  pro- 
verbially lax  with  regard  to  the  notification  of  typhoid  cases,  and  we  may 
assume  that  this  neglect  is  in  part  due  to  the  want  of  any  adequate  quid 
pro  quo  in  return  for  such  notification.  Probably  the  assistance  derived 
from  a  prompt  bacteriological  diagnosis,  or  even  corroboration  of  diag- 
nosis in  the  early  stages  of  typhoid,  will  lead  to  the  more  uniform  report- 
ing of  cases.  Besides  distinguishing  lyphoid  from  such  well-characterized 
diseases  as  tuberculosis  and  malarial  disease,  this  test  may  also  be  ex- 
pected to  clear  up  the  mystery  which  surrounds  those  doubtful  cases  of 
so-called  bilious  fever,  remittent  fever,  gastric  fever,  typho-malarial  fever, 
etc.,  which  are  so  common  in  times  and  places  where  typhoid  is  preva- 
lent, and  rare  in  the  absence  of  typhoid,  at  least  in  temperate  regions 
which  are  free  from  malaria. 

Those  who  are  called  upon  to  investigate  epidemics  of  typhoid  are 
much  perplexed  by  the  large  number  of  cases  of  ill-defined  and  transitory 
fever  occurring  among  those  personally  exposed  to  the  infection,  and  the 
impossibility  of  coming  to  anything  like  a  definite  conclusion  upon  the 
evidence  hitherto  obtainable  as  to  whether  these  are  to  be  regarded  as 
cases  of  abortive  typhoid  or  not.  la  my  own  experience,  such  cases  have 
usually  equaled  or  outnumbered  the  cases  where  the  symptoms  justified 
a  definite  diagnosis. 

I  may  add  a  few  words  with  regard  to  technic.  I  use  a  dry  lens  of 
about  one-fourth  inch  focal  distance.  The  dry  blood  drop  is  partly  dis- 
solved with  germ-free  water,  and  a  drop  of  the  solution  obtained  is  placed 
upon  a  cover  glass  which  has  just  been  passed  through  a  flame  and 
mixed  with  a  drop  of  a  typhoid  bouillon  (a  watery  suspension  of  an  agar 
culture  also  answers  very  well).  This  is  placed  over  a  hollow  cell  sealed 
by  vaseline.  I  control  the  examination  by  comparing  it  with  a  blood 
drop  from  an  undoubtedly  typhoid  case,  and  also  with  normal  blood.  It 
is  also  advantageous  to  place  a  minute  drop  of  the  blood  solution  upon 
the  cover  slip  alongside  the  mixture  of  culture  and  serum,  so  as  to  satisfy 
one's  self  in  negative  cases  that  the  blood  contains  no  motile  bacteria. 
Uniformity  of  temperature  is  the  chief  detail  to  be  attended  to,  as  the 
agglutination  does  not  take  place  so  well  if  the  movements  are  sluggish. 


4 


f 


f 


SERUM  D/AGNOS/S  OF  TYPHOin   FEVER. 


., 


A  hot-water  dish  filled  with  warm  water  forms  a  cheap  and  convenient 
substitute  for  an  incubator,  and  a  simple  warm  stage  made  of  a  sheet  of 
copper  is  also  useful.  In  a  well-warmed  laboratory,  however,  the  use  of 
these  adjuncu  is  unnecessary.  Hollov,  cells  are  convenient,  but  not  in- 
dispensable. For  collecting  the  blood  drop,  any  smooth  surface  suffices ; 
cover  glasses  or  slides  have  the  advantage  of  being  clein  and  sterile,  but 
I  have  found  ordinary  writing  paper  or  smooth  cardboard  most  conve- 
nient, as  it  could  be  more  easily  labeled  or  forwarded.  The  swabs  used 
for  diphtheria  outfits  will  answer,  but  the  presence  of  extraneous  sub- 
stances, such  as  fibres,  was  found  annoying.  The  presence  of  blood  pig- 
ment is  rather  an  advantage,  as  it  enables  the  drop  to  be  more  easily 
focused.  The  small  fibrin  particles  of  clot  sometimes  bear  a  superficial 
resemblance  to  the  islets  of  agglutinated  typhoid  bacilli,  but  are  readily 
distinguished  from  them  by  the  presence  of  leucocytes  in  th^ir  meshes. 

One  advantage  of  having  the  blood  dried  is  that  it  insures  it  against 
contaminating  growth  occurring  during  shipment.  In  case  any  doubt  as 
to  the  reaction  exists  at  first,  it  will  usually  be  dispelled  by  watching  the 
preparations  for  some  hours,  or,  if  necessary,  for  a  day  or  two.  This  per- 
mits a  decided  and  progressive  increase  of  motion  in  non-typhoid  cases 
and  allows  the  more  perfect  agglutination  in  the  genuine  ones. 

The  one  indispensable  factor  is  perfect  purity  of  the  culture.  The  one 
which  I  use  was  kindly  forwarded  me  by  Mr.  J.  J.  Mackenzie,  bacteriolo- 
gist to  the  Ontario  Provincial  Board  of  Health,  and  was  stated  to  have 
come  originally  from  the  Berlin  Hygienic  Institute.  It  grows  typically 
on  gelatin,  potato,  bouillon,  agar,  and  milk ;  reacts  typically  with  litmus 
agar,  produces  no  indol  or  gas,  and  shows  th*  iotility  and  staining  reac- 
tions characteristic  of  the  Eberth  bacillus. 

I  have  made  this  communication  because  the  method  here  suggested 
seems  better  adapted  than  those  hitherto  employed  for  bringing  this  test 
within  the  range  of  ordinary  ^ablic-health  laboratory  work,  and  enabling 
it  to  be  dealt  with,  if  I  may  so  express  it,  in  a  wholesale  manner.^ 

This  article  was  published  m  the  "  New  York  Medical  Journal "  of 
October  31,  1896.  Further  articles  on  the  same  subject  were  published 
by  me  in  the  "  New  York  Medical  Journal,"  November  28,  1896  (with  Dr. 
D.  D.  McTaggart)  in  the  "British  Medical  Journal,"  December  5,  1896; 
Circular  of  the  Board  of  Health  of  the  Province  of  Quebec,  January  7, 
1897  (with  Dr.  D.  D.  McTaggart)  in  the  "Montreal  Medical  Journal," 
March,  1897  ;  "  Centralblatt  fiir  Bakteriologie,"  Baud  XXI,  1897. 

1  Drying  the  blood  as  a  preliminary  step  has  enabled  the  Board  of  Health  of  the  Province  of 
Quebec  to  offer  to  the  medical  profession  here  a  free  public  service  of  typhoid  diagnosis  by  the 
serum  method  similar  to  that  Wi.ich  is  followed  in  diphtheria.  Outfits  consisting  of  a  folded  and 
sterilized  piece  of  paper,  in  which  the  blood  drop  is  sent  inclosed  m  a  suitable  envelope,  are  placed 
in  convenient  depots.  In  case  of  negative  results,  an  additional  ample,  taken  by  collecting  a  few 
drops  of  blood  in  a  small  glass  tube,  is  examined,  but  this  extra  precaution  is  seldom  necessary. 
As  to  the  degree  of  accuracy  which  this  application  of  the  test  may  afford,  it  is  too  early  to  speak 
positively.  From  my  experience  hitherto,  I  ,im  inclined  to  believe  that  it  will  compare  not  un- 
favorably with  those  obtained  in  the  cases  of  diphtheria  and  tuberculosis.  In  one  case  the  reac- 
tion was  present  on  the  third  day. 


8 


SERUM  DIAGNOSIS  OF  TYPHOID  FEVER. 


LABORATORY   OF  THE  BOARD   OF   HEALTH   OF  THE    PROVINCE   OF 

QUEBEC. 

CIRCULAR    ON   ATTENUATED  TEST  CULTURES   AS  A   SAFEGUARD  AGAINST    PSEUDO-REAC- 
TIONS  IN    SERUM    DIAGNOSIS   OF   TYPHOID   BY  THE  DRIED   BLOOD   METHOD. 

Montreal,  7th  January,  1897. 

To  the  President  of  the  Board  of  Health  of  the  Province  of  Qmoec  : 

Sir  :  In  my  work  in  serum  diagnosis  done  jointly  with  Dr.  D.  D.  McTaggart,  we  re- 
cently met  with  a  series  of  peculiar  partial  reactions  in  which  the  dried  blood  solution 
from  many  perfectly  healthy  persoiis  gave  a  very  decided  agglutination.  The  blood 
serum  from  the  same  persons  was  found  much  less  liable  to  give  these  pseudo-reactions. 
This  made  it  less  easy  to  exclude  other  febrile  diseases,  and  as  with  this  test  accuracy 
in  the  negative  diagnosis  :c  of  great  practical  importance,  others  who  may  meet  with 
similar  pseudo-reactions  will  be  interested  in  learning  how  they  may  be  avoided. 

These  pseudo-reactions  were  not  encountered  in  our  earlier  cases  when  attenuated  cul- 
tures were  used.  They  beg?,ii  to  appear  when  we  employed  a  short  time  virulent  cul- 
tures, and  disappeared  air?.in  on  resuming  the  use  of  attenuated  ones.  Active,  virulent 
cultures,  intensified  by  daily  transplantation  and  growth,  at  the  body  temperature,  are 
therefore  not  suitable  for  the  dried  blood  test.  Where  only  active  cultures  are  em- 
ployed, we  do  not  think  that  the  dried  blood  method  can  be  considered  to  have  had  a 
fair  trial. 

The  explanation  of  this  difference  appears  to  be  that  the  serum  contains  relatively  less 
of  the  substances  causing  agglutination  than  solution  of  the  entire  blood.  Hence  solu- 
tions of  the  entire  blood  react  more  intensely  to  the  test  than  solutions  of  the  blood 
serum  alone.    This  was  the  reverse  of  what  we  had  anticipated. 

It  is  found  that  old  laboratory  stock  cultures  kept  at  room  temperature,  and  trans- 
planted at  intervals  of  about  one  month,  give  us  the  best  results.  Bouillon  test  cultures 
grown  from  this  stock  for  twelve  to  twenty-four  hours  at  body  temperature  are  found  to 
react  decisively  with  solutions  of  typhoid  blood  or  typhoid  serum,  the  reaction  being,  as 
a  rule,  well  marked  within  fifteen  minutes.  With  non-typhoid  blood  or  serum  solutions, 
the  same  test  cultures  give  no  reaction  even  after  twenty-four  or  forty-eight  hours'  con- 
tact. Intraperitoneal  injection  of  one  c.  c.  of  such  living  bouillon  culture  produces  in 
guinea  pigs  a  marked  blood  reaction  and  immunity  without  much  disturbance  of  health. 
We  find  that  the  best  results  in  cases  of  dried  blood  are  obtained  with  cultures  where 
the  motion,  as  seen  under  the  microscope,  is  of  a  rapid,  gliding  character,  but  free  from 
darting  movements.  If  the  movement  is  sluggish,  owing  to  too  great  attenuation  of  the 
culture,  ?  few  daily  transplantations  at  body  temperature  will  make  it  more  active. 
Exact  estimation  of  the  degree  of  dilution  has  not  been  found  necessary  for  ordinary 
diagnostic  work  when  attenuated  cultures  are  used.  A  very  faint  tint  in  the  drop  exam- 
ined usually  indicated  suflScient  strength.    The  solution  should  nc;  be  thick  and  viscid. 

All  the  results  which  I  have  reported  ("  N.  Y.  Medical  Journal,"  Oct.  3,  1896,  and 
"  British  Medical  Journal,"  Dec.  s>  1896,)  were  obtained  with  attenuated  cultures.  A 
report,  giving  some  additional  technical  details,  has  been  prepared,  and  can  be  sent  to 
any  who  desire  further  information. 

I  remain,  yours  respectfully, 

Wyatt  Johnston, 
Bacteriologist  to  the  Board  of  Health,  Proi<ince  of  Quebec. 


Note. — Subsequent  experience  has  confirmed  the  above  statements  as  to  the  best  method  of 
technique  with  the  cultures  which  I  have  used.  From  the  recent  literature  of  the  subject  it  seems, 
however,  established  that  the  cultures  used  by  others  give  the  best  results  under  different  condi- 
tions, so  that  it  is  safer  not  to  generalize. 


